Ontario Provincial Police Const. David Dionne displayed “jaw-dropping” behaviour and a “lack of courage” when he failed to respond to a dying woman’s 911 call, a police superintendent has ruled.

Dionne pleaded guilty to two counts of neglect of duty at an OPP disciplinary hearing Feb. 14 and has been demoted from first- to second-class constable for two years. Dionne’s lawyer said the rank reduction would entail a salary loss of about $32,000, according to a document filed as part of the disciplinary proceeding.

When 54-year-old Kathryn Missen called 911 from her home in Casselman on Sept. 1, 2014, she was struggling to breathe. According to the OPP’s disciplinary decision, Dionne was dispatched to Missen’s home at 6:16 p.m. When OPP dispatch asked Dionne about the incident approximately nine hours later, Dionne reported that there was “trouble on the (phone) line,” and cleared the call, saying no other action was necessary, according to disciplinary documents.

In fact, Dionne never visited Missen’s residence. Police found Missen dead two days later, on Sept. 3, after a concerned neighbour called police.

Missen had suffered from asthma since birth, according to her sister, Brenda Missen, but was typically able to manage it without medical intervention.

“She had never called 911 before. So, if she was calling 911, it meant that it was very serious,” Brenda said.

Brenda believes a prompt response from emergency services could have saved her sister’s life.OPP Supt. Robin McElary-Downer accepted a joint submission from Dionne’s lawyer and the lawyer representing Missen’s family, both of whom called for a two-year demotion to second-class constable.

While the OPP decision focuses on Dionne, Missen’s sister believes culpability goes beyond a single officer. A coroner’s inquest will examine Missen’s death as part of a larger inquest into the province’s 911 responses.

“I’m sure that my sister would not want any individuals blamed for her death,” said Brenda. “It was clearly a huge failure of the system. And so our focus has always been on having the system changed.”

People who could shed further light on the circumstances of Missen’s death declined to comment to the Citizen, including a lawyer for Dionne, an OPP spokesperson and the Ministry of Community Safety and Correctional Services.

As the Missen family sought answers, Steven Dick, a friend of Missen’s who has been designated as a public complainant in the proceedings, and is acting as a representative for the family, filed a report about the response to the initial 911 call.

Dick, a former Ottawa firefighter, said he prepared the report for the regional coroner and based it on information received from the OPP and Office of the Independent Police Review Director.

Missen’s call was received at a North Bay communications centre, where an operator spent “43 seconds listening to Kathryn moan, wheeze and desperately attempt to communicate her emergency.” About two and a half minutes into the call, the operator transferred the call to a Smiths Falls call centre, where another operator ran through a list of questions, but received no response.

At that point, Missen was likely “incapacitated,” Dick said.

The operator ended the call and attempted to call back, but could not make contact because Missen’s phone was off the hook. The operator “more or less … (gave) up on that call.”

More than 90 minutes after Missen’s call, as the Smiths Falls dispatcher’s shift was winding down, she contacted the OPP and asked Dionne to go to Missen’s home. Dick described the conversation between Dionne and the operator as dominated by “jocular, informal bantering.”

Dionne was found guilty of neglect of duty and deceit after a disciplinary hearing in 2016, but McElary-Downer later voided that decision and declared a mistrial.

Lawyers for all parties agreed a mistrial was necessary after learning Dionne’s former counsel, James Girvin, also represented OPP Const. Michael Cunning. Cunning and a colleague found Missen dead in her home on Sept. 3 after a neighbour told police he had not seen Missen recently.

Because of his involvement, Cunning was a prosecution witness during Dionne’s 2016 hearing. This meant that in cross-examining Cunning, Girvin was actually questioning his own client.

A new hearing was rescheduled for Jan. 30.

Officers testified during Dionne’s 2016 hearing that Missen’s phone was off the hook when they found her, and that the cord had been pulled out from the wall. The phone connected to 911 when an officer hit redial.

Dick says dispatchers missed several opportunities to send first responders to Missen’s home.

“The failures on this call are just incomprehensible,” he said.

“Why didn’t they send ambulance? Why didn’t they send fire?”

The OPP has also laid a deceit charge against Cunning for his actions following Missen’s death. Cunning allegedly gave false information to investigators from the Office of the Independent Police Review Director, according to a hearing notice from the OPP.

According to the document, Cunning spoke with Dionne on Sept. 3, and later told the OIPRD that the officer could not remember if he “attended a specific residence” after Missen’s 911 call.

“This was not true,” according to the notice. Cunning also testified during Dionne’s previous hearing that he had lost his notes about the Casselman incident.

Cunning’s disciplinary hearing resumes on Friday in Smiths Falls, an OPP inspector said in an email.

Kathryn Missen found dead in Casselman, Ont., home in 2014, Const. David Dionne demoted for 2 years

An Ontario Provincial Police constable who failed to respond to a dying woman's 911 call, cleared the call hours later despite never having gone to her home, and implied to a dispatcher that he had taken action when he had not, has been demoted for two years after pleading guilty to neglect of duty.

At about 4:45 p.m. on Sept. 1, 2014, 54-year-old Kathryn Missen dialled 911 from her home in Casselman, Ont., southeast of Ottawa, according to the OPP's disciplinary decision.

She was in medical distress, according to her family, and was unable to speak.

OPP Const. David Dionne was dispatched to the home at about 6:15 p.m. He was told by the dispatcher that no one spoke during the 911 call, and that Bell Canada confirmed there was trouble on the phone line.

Nine hours later, the dispatcher contacted Dionne to ask what was going on. Dionne cleared the call, saying "Confirmed trouble on line, NFA" (NFA stands for no further action).

Missen was found dead in her home two days after her 911 call, on Sept. 3, when a neighbour who was concerned about Missen's well-being called OPP.

'You have now seen us at our worst'

Dionne was charged with two counts of neglect of duty, and pleaded guilty at an OPP disciplinary hearing in January 2017.

In February 2017, OPP Supt. Robin McElary-Downer demoted Dionne from first-class constable to second-class constable for a period of two years, which will amount to about $32,000 in lost salary.

"Commendably, you found the inner strength to [voice your concerns] during your darkest days," McElary-Downer wrote in her penalty decision, addressing Missen's family directly.

"Your complaint exposed the OPP's failure to respond; you have now seen us at our worst and know intimately how we let down your loved one when she needed us most. For this I am truly sorry. I can only hope that one day we can prove to you that this moment in time does not define who we really are."

In July 2016, McElary-Downer found Dionne guilty of neglect of duty and deceit, but a mistrial was granted after it came to light that Dionne's then lawyer represented another officer charged in relation to the incident.

The other officer was later found not guilty of deceit in a separate decision.

Coroner's inquest announced

A coroner's inquest, announced in early February, will examine whether flaws in the province's 911 system and the co-ordination of emergency responders may have contributed to Missen's death, as well as the deaths of three people in Sudbury, Ont., in a boating incident in 2013.

Missen's relatives said in a news release in February that they're relieved an inquest is being held.

"So many errors, delays and miscommunications were made in the minutes and hours after Kathryn called 911 that there is clearly a huge systemic problem," said Brenda Missen.

"And, sadly, the case in Sudbury shows that it was not just an isolated event. We are so relieved this joint inquest is going forward. We hope recommendations will be made and put in place so that this never happens to anyone else."

Kathryn Missen died from severe asthma attack at her home in Casselman, Ont.

The Ontario Provincial Police officer who failed to check on a dying Casselman, Ont., woman who had called 911 for help four years ago apologized to her family in Ottawa Tuesday during a coroner's inquest into the death and the emergency response to it.

Kathryn Missen, 54, was suffering a severe asthma attack on the afternoon of Sept. 1, 2014, when her frantic 911 call reached an operator at the OPP emergency call centre in North Bay, Ont., 400 kilometres away. The operator, who testified Monday, couldn't understand what Missen was saying.

The operator transferred the call to OPP in Smiths Falls, Ont., where it took a dispatcher there 90 minutes to contact the police detachment in Embrun​, Ont., and advise an officer to go to Missen's home, about 25 kilometres away.

The inquest heard the Smiths Falls dispatcher determined from the phone company that there was "a problem with [Missen's] line."

'Trouble on the line'

OPP Const. David Dionne, 34, told the inquest he "gasped" when he learned the call had first been placed 90 minutes earlier.

"It made me believe it was a technical issue with the phone line," he said. "I've had this happen many times."

Dionne said he then got busy responding to other 911 calls and "didn't remember about [Missen's] call."

The dispatcher in Smiths Falls called Dionne back 11 hours later to ask what had come of the call.

"I confirmed there was trouble on the line," Dionne testified.

Term interpreted differently

Kathryn Missen's sister, Brenda Missen, who attended the inquest, said the family has been told "trouble on the line" can mean different things.

"It can mean anything," she said. "Trouble on the line can mean the cord has been pulled out of the wall by an angry husband, or the line has been burned up in a fire. You can't tell what trouble on the line means unless you physically go to the house."

Dionne didn't go to Missen's home, despite OPP policy to check up on every 911 call.

"Based on my past experience with similar calls, I was 100 per cent sure it was a technical problem with the phone rather than someone who needed help," he testified.

Dionne was asked what he'd have done had he known the woman on the other end of the line was heard gasping and moaning when she first placed the 911 call.

"I would have dropped everything to go and save her," he said, breaking down. "A human life is the most important thing that is out there."

Officer demoted

Last year Dionne pleaded guilty to two counts of neglect of duty in relation to the incident and was demoted from first to second-class constable for two years. Dionne has been on leave from the OPP for a little more than two years.

Dionne addressed Missen's three sisters and daughter, some of whom he'd met at his earlier disciplinary hearing.

"I haven't forgiven myself for what happened," he told them. "When you hugged me at my hearing, 10,000 pounds was lifted off my shoulders. There's not a day goes by that I don't think about Kathryn. She appears in my dreams and she is smiling.

"I sincerely want to apologize for everything you have had to go through — the failure of an organization and my part in that," he continued. "It's been really hard for me, and I don't think I will return to policing, and that's just the way it is."

Brenda Missen said her family doesn't hold Dionne responsible for her sister's death, and instead placed the blame on the convoluted system for handling 911 calls in the province.

The inquest continues Wednesday, and is scheduled to continue until Nov. 2.